Knowledge Base Category -

Q:

Have Medicare Contractors started performing Medical Reviews again?

A:

On July 6, 2020, CMS released the document Coronavirus Disease 2019 (COVID-19) Provider Burden Relief Frequently Asked Questions (FAQs). The very first FAQ addresses Medicare Fee-for-Service medical reviews.

Q. Is CMS suspending most Medicare Fee-For-Service (FFS) medical review during the Public Health Emergency (PHE) for the COVID-19 pandemic?

A. On March 30 CMS suspended most Medicare Fee-For-Service (FFS) medical review because of the COVID-19 pandemic. This included pre-payment medical reviews conducted by Medicare Administrative Contractors (MACs) under the Targeted Probe and Educate program, and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractor (SMRC) reviews and Recovery Audit Contractor (RAC). As states reopen, and given the importance of medical review activities to CMS’ program integrity efforts, CMS expects to discontinue exercising enforcement discretion beginning on August 3, 2020, regardless of the status of the public health emergency. If selected for review, providers should discuss with their contractor any COVID-19-related hardships they are experiencing that could affect audit response timeliness. CMS notes that all reviews will be conducted in accordance with statutory and regulatory provisions, as well as related billing and coding requirements. Waivers and flexibilities in place at the time of the dates of service of any claims potentially selected for review will also be applied.

American Hospital Association Letter to CMS

The American Hospital Association (AHA) expressed concern about CMS’s decision to resume medical review audits on August 3, 2020 in a July 29, 2020 letter to CMS Administrator Seema Verma. The letter ends with the AHA stating that “to be clear, we urge the agency to refrain from differentiation between medical review audits and the other flexibilities you have created, and instead ensure all of the relevant waivers remain active during the pandemic.”

Medicare Administrative Contractors (MACs) Guidance

On August 4, 2020, Palmetto GBA posted an article to their website providing additional detail about the resumption of medical reviews. Specifically,

• Beginning August 17th, the MACs are resuming post-payment reviews of items/services provided prior to March 1, 2020,
• The Targeted Probe and Educate (TPE) program will restart later, and
• MACs will continue to offer detailed review decisions and education as appropriate.

CMS included this same guidance in their August 6, 2020 MLNConnects e-newsletter.

Q:

Does a provider have to explicitly link a respiratory condition to COVID-19, if the COVID-19 test is positive?  For example:  Pneumonia with a positive COVID-19 test.

A:

No. A provider does not need to explicitly link the results of the COVID-19 test to the respiratory condition, as long as the positive test result itself, is part of the medical record.  For the example above, code U07.1 (COVID-19) as the principal diagnosis with code J12.89 (Other Viral Pneumonia) as a secondary diagnosis.

References:

Frequently Asked Questions Regarding ICD-10-CM Coding for COVID-19

Coding Clinic for ICD-10-CM/PCS, Second Quarter 2020: Page 3, effective May 29, 2020.

Q:

What are the determining factors for when a procedure is performed for diagnostic versus therapeutic purposes?

A:

First, determine the objective of the procedure.  Is the procedure performed to:  

• Make a diagnosis, or
• Eliminate a condition?

For example, a physician may remove all necrotic tissue that is present in a slow healing wound.  A sample of that tissue was sent to pathology to see what organisms may be growing. This would be a therapeutic removal of tissue as the objective was to remove all of the necrosis to promote wound healing.

Another example is found in Coding Clinic, Third Quarter 2017, page 12, which addresses the coding of abdominal paracentesis. The advice found here tells us to use the qualifier ‘Z’ if there is a therapeutic component to the procedure (0W9G3ZZ, Drainage of Peritoneal Cavity, Percutaneous Approach).  The physician may send a fluid sample to pathology to look for malignant cells or leukocytes. However, the objective of the paracentesis is to relieve the pain and discomfort from ascites, which is a therapeutic procedure.

It is important to note that if both a diagnostic and therapeutic paracentesis are performed separately, then both should be coded.

Biopsies are good examples of diagnostic procedures, such as, a pancreas biopsy in a patient with a pancreatic mass or bone marrow biopsy for unexplained anemia.

Q:

What recourse do we have when a claim has been denied by the SMRC for no receipt of documentation requested?

A:

Noridian is the nationwide SMRC who conducts medical reviews as directed by CMS. If you have received a denial for no receipt of documentation requested you would need to do the following:

• Submit documentation to the Medicare Administrative Contractor (MAC), who issued the demand letter for overpayment within 120 calendar days of the demand letter.
• This situation is considered a reopening and the MAC will send the submitted information to the SMRC for a re-review decision.
• The SMRC has 60 days to make a decision and will mail a letter to the supplier with their findings to pay the claim or outline why the claim is being denied.
• The SMRC will also notify the MAC of the payment or denial decision.
• The MAC will then adjust the claim and a remittance advice with the adjustment results will be generated.
• If a claim remains denied, you have the right to appeal the SMRC decision.

The SMRC website can provide you with additional information about their medical review process and how to respond to an Additional Documentation Request (ADR).

Q:

Can you help me understand what a provisional affirmation prior authorization (PA) decision is as it pertains to the Outpatient Prior Authorization Program set to begin on July 1, 2020? 

A:

Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M posted the following information about the Outpatient Department Prior Authorization in their June 22, 2020 Daily Newsletter:

“A provisional affirmation prior authorization (PA) decision is a preliminary finding that a future claim submitted to Medicare for the service(s) likely meets Medicare’s coverage, coding and payment requirements. The provisional affirmation PA decision is valid for 120 days from the date decision was rendered.

Palmetto GBA's Outpatient Department Prior Authorization Calculator will help you determine the time you have remaining to perform the approved procedure before the authorization expires. Just enter the date of the Prior Authorization Affirmation and click Calculate. The tool will tell you the last date your authorization will be valid.”

• Jurisdiction J Part A Outpatient Department Prior Authorization Calculator
• Jurisdiction J Part B Outpatient Department Prior Authorization Calculator
• Jurisdiction M Part A Outpatient Department Prior Authorization Calculator
• Jurisdiction M Part B Outpatient Department Prior Authorization Calculator

Q:

Has CMS released information about the July 2020 Hospital Outpatient Prospective Payment System update? 

A:

Yes. On June 5th CMS released Change Request 11814 - Transmittal R10166CP and related MLN Article MM1184. This recurring update notification describing changes to and billing instructions for various payment policies implemented in the July 2020 OPPS update. This update includes changes in response to the COVID-19 pandemic and the secretary declaring a public health emergency (PHE). Following is a list of key updates for July 1, 2020:

• COVID-19 Laboratory Tests and Services and Other Laboratory Tests Coding Update
• Status Indicator Changes for Certain Virtual Services (Telephone services)
• New Telehealth Code for a Telehealth Distant Site Service Furnished by a Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC) Only
• Other Telehealth Distant Site Codes for RHCs and FQHCs in the OPPS Addendum B and I/OCE
• New CPT Category III Codes Effective July 1, 2020
• The American Medical Association (AMA) released CPT Category III codes twice a year: In January, for implementation beginning the following July, and in July, for implementation beginning the following January. CMS is implementing 25 CPT Category III codes on July 1, 2020.
• CPT Proprietary Laboratory Analyses (PLA) Coding Changes Effective July 1, 2020
• The AMA CPT Editorial Panel deleted five PLA codes (CPT codes 0124U through 0128U) and established 30 new PLA codes (CPT codes 0172U through 0201U)
• Hemodialysis Arteriovenous Fistula (AVF) Procedures: Replacement Codes for HCPCS Codes C9754 and C9755
• New Device Pass-Through Categories
• New CY 2020 HCPCS Codes and Dosage Descriptors for Certain Drugs, Biologicals, and Radiopharmaceuticals Receiving Pass-Through Status
• There are eleven new HCPCS codes for reporting drugs and biologicals in the hospital outpatient setting, where there have not previously been specific codes available (i.e., C9059 Injection, meloxicam, 1mg).
• Currently Existing HCPCS Codes for Certain Drugs, Biologicals, and Radiopharmaceuticals That Will Start To Receive Pass-Through Status
• Currently Existing HCPCS Codes for Certain Drugs, Biologicals, and Radiopharmaceuticals With Pass-Through Status Ending on June 30, 2020
• Drugs and Biologicals that have Changes to Status Indicators 
• Newly Established HCPCS Codes for Drugs, Biologicals, and Radiopharmaceuticals as of July 1, 2020
• Skin Substitutes – New Products
• New Separately Payable Procedure Codes – Surgical Procedures
• New HCPCS Codes Describing Strain-Encoded Cardiac Magnetic Resonance Imaging (MRI)
• New HCPCS Codes Describing Peripheral Intravascular Lithotripsy
• Supervision of Outpatient Therapeutic Services
• This section discusses several changes that have been made in response to the COVID-19 outbreak and the Secretary declaring the existence of a public health emergency (PDE).

Finally, CMS reminds providers that “the fact that a drug, device, procedure or service is assigned a HCPCS code and a payment rate under the OPPS does not imply coverage by the Medicare program, but indicates only how the product, procedure, or service may be paid if covered by the program. MACs determine whether a drug, device, procedure, or other service meets all program requirements for coverage. For example, MACs determine that it is reasonable and necessary to treat the beneficiary’s condition and whether it is excluded from payment.”

Resources:

Link to Transmittal: https://www.cms.gov/files/document/r10166cp.pdf

Link to MLN Article MM11814: https://www.cms.gov/files/document/mm11814.pdf

Q:

What is the Prior Authorization for Certain Outpatient Department (OPD) Services Program and what resources are available to learn more about the program?

A:

The program was finalized in the Calendar Year (CY) 2020 Outpatient Prospective Payment System (OPPS) Final Rule and is specific to the Hospital Outpatient Department setting. A Prior Authorization will be required for the following five procedures:

• Blepharoplasty
• Botulinum toxin injections
• Panniculectomy
• Rhinoplasty
• Vein ablation

You can access a list of the specific HCPCS codes for each of these procedures on the CMS Prior Authorization for Certain Hospital OPD Services webpage.

CMS believes this program will be an effective tool in controlling unnecessary increases in volume by ensuring payments are only being made for medically necessary services.

As required by CMS, Medicare Administrative Contractors have been educating providers about this program by posting information on their websites and webinars. Likewise, CMS has created a webpage with information specific to this program and held a Special Open Door Forum on May 28, 2020.

This program is set to begin July 1, 2020. However, a week from today on June 17, 2020, hospitals can begin submitting prior authorization requests (PARs) to Medicare Administrative Contractors for services to be provided on or after July 1, 2020.   

Following are links to resources to assist you as you prepare for this new program:

• CMS Prior Authorization for Certain Hospital OPD Services webpage https://www.cms.gov/research-statistics-data-systems/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/prior-authorization-certain-hospital-outpatient-department-opd-services
• Note, this page includes a link to the list of applicable HCPCS codes for the program, the ODF slides, an FAQ document about the program and an Operational Guide.
• Calendar Year 2020 Outpatient Prospective Payment System Final Rule https://www.govinfo.gov/content/pkg/FR-2019-11-12/pdf/2019-24138.pdf
• Note, information about this program starts on page 61446
• Palmetto GBA Outpatient Department PA https://www.palmettogba.com/palmetto/providers.nsf/docsr/Providers"JJ%20Part%20A"Medical%20Review"Outpatient%20Department%20PA
• Note, this page include articles about the program. The last article was posted on June 3rd and is an OPD eServices Submission Guide.

Q:

How do you code Type 2 Diabetes Mellitus with Peripheral Neuropathy?  Is Polyneuropathy the same as Peripheral Neuropathy in Diabetes?

A:

Yes.  According to the ICD-10-CM Code Book, Type 2 Diabetes Mellitus with Peripheral Neuropathy codes to Type 2 Diabetes Mellitus with Polyneuropathy (E11.42).  Let’s follow the alphabetic index:

Neuropathy

                        peripheral (nerve) (see also Polyneuropathy) G62.9

            In order to capture Diabetes Mellitus, we need to ‘see also Polyneuropathy’.

                Polyneuropathy (peripheral) G62.9

                Notice that (peripheral) is a modifier for polyneuropathy

                                diabetic - see Diabetes, polyneuropathy

                When we ‘see Diabetes, polyneuropathy’, it takes us to:

                Diabetes, diabetic; due to underlying condition; with; polyneuropathy E08.42

                Under the code category for E08, there is an Excludes1 note for several conditions, including type 2 diabetes mellitus.

                type 2 diabetes mellitus (E11.-)

Go to E11 Type 2 diabetes mellitus

                                E11.4 Type 2 diabetes mellitus with neurological complications

                                                E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy

Polyneuropathy means multiple nerve damage is causing peripheral neuropathy.  These are the nerves that connect your spinal cord to the rest of your body.  Both these terms are often used at the same time and generally mean the same thing.

References

ICD-10-CM Official Code Set

https://www.empowher.com/community/ask/what-difference-between-peripheral-neuropathy-and-poly-neuropathy

Q:

I know that the new MOON is available for use. What I don’t know is when are we required to use the new form?

A:

The new CMS 10611-MOON has been approved by the Office of Management and Budget (OMB) and has an expiration date of 12/31/2022. The following update was posted to the CMS MOON webpage on April 6, 2020:

“Hospitals are strongly encouraged to begin using the new Medicare Outpatient Observation Notice (MOON) as soon as possible, but no later than May 1, 2020.

Also, keep in mind the following guidance from CMS regarding the delivery of Beneficiary Notices during the COVID-19 public health emergency:

If you are treating a patient with suspected or confirmed COVID-19, CMS encourages the provider community to be diligent and safe while issuing the following beneficiary notices to beneficiaries receiving institutional care:

• Important Message from Medicare (IM)_CMS-10065
• Detailed Notices of Discharge (DND)_CMS-10066
• Notice of Medicare Non-Coverage (NOMNC)_CMS-10123
• Detailed Explanation of Non-Coverage (DENC)_CMS-10124
• Medicare Outpatient Observation Notice (MOON)_CMS-10611
• Advance Beneficiary Notice of Non-Coverage (ABN)_CMS-R-131
• Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNFABN)_CMS-10055
• Hospital Issued Notices of Non-Coverage (HINN)

In light of concerns related to COVID-19, current notice delivery instructions provide flexibilities for delivering notices to beneficiaries in isolation. These procedures include:

• Hard copies of notices may be dropped off with a beneficiary by any hospital worker able to enter a room safely. A contact phone number should be provided for a beneficiary to ask questions about the notice, if the individual delivering the notice is unable to do so. If a hard copy of the notice cannot be dropped off, notices to beneficiaries may also be delivered via email, if a beneficiary has access in the isolation room. The notices should be annotated with the circumstances of the delivery, including the person delivering the notice, and when and to where the email was sent.
• Notice delivery may be made via telephone or secure email to beneficiary representatives who are offsite. The notices should be annotated with the circumstances of the delivery, including the person delivering the notice via telephone, and the time of the call, or when and to where the email was sent.

Resource: MLN Matters SE20011 at https://www.cms.gov/files/document/se20011.pdf

Q:

How would Anxiety due to a medical condition be coded?

A:

Per Coding Clinic, 4th quarter 1996, page 29, Anxiety due to a medical condition is assigned to Organic anxiety syndrome (293.84), which crosswalks in I-10 to Anxiety Disorder Due to Known Physiological Condition (F06.4).  Per Coding Clinic, “This condition is characterized by clinically significant anxiety that is judged to be due to the direct physiological effects of a general medical condition.”

Below are some organic conditions that can cause Anxiety:

• Hypo and Hyperthyroidism,
• CHF,
• COPD,
• Pneumonia,
• Neoplasms

References:

• Coding Clinic, 4th Quarter 1996, page 29
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071743/